S. Nanda, A. K. Sharma, and Simran; All India Institute of Medical Sciences(AIIMS), Raipur, Raipur, India
Purpose/Objective(s):
In India, CNS tumors account for 2% of all malignancies, of which 59.5% are High-Grade gliomas (HGG). HGG remains a challenge in neuro-oncology, necessitating advances in treatment strategies. Conventional radiotherapy is the cornerstone of treatment, but alternative fractionation schedules may offer potential benefits. This study compares 60 Gy in 30 fractions over 6 weeks with a hypofractionated schedule of 53.4 Gy in 20 fractions over 4 weeks in elderly HGG patients, evaluating tumor control and clinical response, patient compliance, and toxicity profiles. Materials/Methods:
In this randomized controlled pilot study, 31 patients =50 years with pathologically confirmed HGG were randomized either to Conventional RT (60 Gy/30 fr/6 weeks) or Hypofractionated RT (53.4 Gy/20 fr/4 weeks). Exclusion criteria were prior brain RT or metastatic disease. Patients underwent CT simulation, following which contouring was done on fused CT sim – post op MRI images as per ESTRO-EANO guidelines. Upon plan approval, RT was delivered using VMAT technique. All patients received concurrent temozolomide, dosed by BSA, 30 min before starting RT. Weekly toxicity assessments were done using RTOG criteria. Post-RT, patients had monthly follow-ups for 6 months with neurological examination(NANO Scoring), KPS, blood tests, QLQ-BN20 QoL assessments at each follow up and a post-treatment MRI was done at 6 weeks. Data analysis was done using statistical software.
Results:
31 patients met the inclusion criteria. Mean/median age (years) for hypofractionated RT was 53.73 ± 6.39/53 (IQR 50-57) and 50.63 ± 7.75/50 (IQR 44.3-56.7) for conventional RT. Both groups had ~60% males, ~40% females, and comparable KPS (80) and ECOG (1) scores (p=0.740, p=0.683). NANO scores at follow-ups indicated stability, response, and progression in 6(42.9%), 3(1.4%), and 5(35.7%) patients in hypofractionated RT arm vs. 8(53.3%), 4(26.7%), and 3(18.75%) patients in conventional RT arm (p=0.710). RANO scores at 6 weeks were comparable between the two arms(p=1.00). No significant differences in NANO domain wise scores at baseline and each follow up or QoL at baseline (28 vs. 27.5, p=0.379) and each follow up among the two groups. CNS toxicity grade I occurred in 73.3% of patients in the hypofractionated RT arm and 100% patients in the conventional RT arm. All patients in both groups had grade I skin toxicity, with no temozolomide-associated toxicity observed.
Conclusion:
Hypofractionated RT is a viable option for HGG, especially in patients =50 years of age, with high completion rates, shorter treatment duration, and better resource utilization. Comparable NANO, QoL, and toxicity outcomes suggest that 53.4 Gy in 20 fractions over 4 weeks (owing to its comparable BED) is an effective, economical alternative for elderly or less mobile patients in resource-limited settings.
